=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508069451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRFIELD PERIODONTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 BEACH RD
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-255-7771
-----------------------------------------------------
Fax | 203-255-5753
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 BEACH RD
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-255-7771
-----------------------------------------------------
Fax | 203-255-5753
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. CARY ALAN SHAPOFF
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 203-255-7771
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------